This is not your Medical Insurance Policy; contact your insurance carrier (or agent) to make changes to your

insurance.

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record
information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date
of birth, and other information that will allow us to identify you. We may also ask to see your drivers license or other identifying documents.

ACCOUNT HOLDER INFORMATION (Please print clearly)
Drivers License # _________________________ State of Issue ________
Name ___________________________________ Social Security #___________________ Date of Birth________________
Email Address (Required) __________________________________________ Mothers Maiden Name__________________
Mailing Address ________________________________________________________________________________________
City____________________________________________ State__________________ Zip______________
Home Phone (_______) _______________ Work Phone (_______) ________________
Residential Address (not a PO Box) ________________________________________________________________________
City____________________________________________ State__________________ Zip______________

AUTHORIZED SIGNER (OPTIONAL)
Since IRS regulations require that only one individual owns the HSA Account, the account holder may want their spouse and/or authorized signer to write checks or
use their Debit Card. I (account holder) hereby designate the following individual as additional authorized signer on my Health Savings Account.

Name ______________________________________ Social Security #__________________ Date of Birth_______________

INSURANCE INFORMATION
Insurance Carrier______________________________ Effective Date of Policy________________ Deductible $________
(Check One) ___Single Insurance Coverage ___Dependent Insurance Coverage
EMPLOYER INFORMATION
Div #: ______________ Name of Employer _______________________________________________________________

PAYMENT ENCLOSED WITH APPLICATION: Opening Deposit (minimum $10.00) $__________
Annual Fee ($36.00) $__________

TOTAL ENCLOSED AMOUNT: $__________






BENEFICIARY INFORMATION

In the event of my death, I name as my beneficiary (shares must equal 100%):

Name ___________________________________ Name __________________________________
Relationship ____________________________ Relationship _______________________________
Share (% of Holding) _______________________ Share (% of Holding) _________________________


www.AmericanHealthValue.com
800-914-3248


Agent ID #: _________________________
Agent Name: __________________________

Grp#/Div: ________________ BenCalc: ___________ Ck# __________
Paid Thru____________
BENEFICIARY INFORMATION CONTINUED ON BACK
Copyright American Health Value, LLC 2012 All Rights Reserved File: Form-Application-Bancorp Revised 09-29-13
Paid Through Date: _____/______/__________
Open Date: ____________ Acct #: ___________ Billing Month: ________________
Office Use Only
0
BENEFICIARY INFORMATION CONTINUED

Spousal Consent: To be completed if your spouse is not listed as your primary beneficiary. This section should be reviewed if either the trust of
the residence of the HSA holder is located in a community or marital property state or the HSA holder is married. Due to important tax consequences of
giving up ones community property interest, individuals signing this section should consult with a competent or legal tax advisor:

CURRENT MARITAL STATUS

I am not married I understand that if I become married in the future, I must complete a new HSA Designation of Beneficiary form.
I am married I understand that if I chose to designate a primary beneficiary other than my spouse, my spouse must sign below.

I am the spouse of the above named HSA holder. I acknowledge that I have received a fair and reasonable disclosure of my spouses property and
financial obligations. Due to the important tax consequences of giving up my interest in this HSA, I have been advised to see a tax professional. I
hereby give the HSA holder any interest I have in the funds or property deposited in this HSA and consent to the beneficiary designation indicated
above. I assume full responsibility for any adverse consequences that may result. The Custodian gave no tax or legal advice to me.

Spouse Signature Required Date Notary Signature Required Date


ACCEPTANCE OF TERMS:
By my signature below I understand that ANNUAL FEES are NON-REFUNDABLE and I apply, and the institution by its signature accepts my application
to establish a Health Savings Account pursuant to the terms of the Health Savings Account Agreement and Disclosure Statement (available at
www.ahvthebancorp.com), which is incorporated into this application by reference. I authorize the bank to provide American Health Value all data
necessary to maintain the account. I/We authorize the transfer of information, as necessary, from my/our account at The Bancorp Bank to my/our
account at American Health Value for the purpose of providing bank account summary information.
I understand the American Health Value administrative fee will automatically be deducted from my Health Savings Account on an annual basis. In the
event there are not adequate funds in my account to cover the annual fee, you may bill the credit card listed below as an alternate payment source.
Card Type Name on Account Account Number Expiration

VISA/MASTERCARD
- - -

The account holder is responsible for the establishment and maintenance of this account pursuant to Federal guidelines. American Health Value is here
to assist the account holder in accomplishing this.
HEALTH SAVINGS ACCOUNT TRUST AGREEMENT:
I acknowledge that I reviewed the Health Savings Account Trust disclosure statement (available at www.ahvthebancorp.com). The trustee or
administrator is authorized to act without further inquiry in accordance with writings bearing my signature. I understand that I may revoke the agreement
by written notice to the trustee or administrator within seven (7) days after the date of the agreement as specified below.
This deposit account is subject to all applicable rules and regulations adopted by The Bancorp Bank. My signature acknowledges my acceptance of the
Truth in Savings Disclosure governing these accounts. The Bancorp Bank may order a consumer report from a credit-reporting agency in order to
evaluate whether to issue a Debit Card for those consumers who have applied. The Truth in Savings Disclosure is available at
www.ahvthebancorp.com.
I authorize my Benefit Administrator, American Health Value, and/or The Bancorp Bank (Bank) to make credit and debit entries to my Checking
Account/HSA (Account), where the Bank is the custodian thereof, for the sole purpose of correcting any contributions that may be made in error to my
Account. For purposes of this Authorization, Bank may also be referred to as the Depository.
Primary Applicant Signature Required Date Authorized Signer Signature Required Date


Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (TIN) (or I am waiting for a
number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding under Internal Revenue
Service (IRS) regulations, or (b) I have not been notified by the Internal Revenue Service that I am subject to backup withholding as a result of failure to
report all interest or dividends, or (c) the Internal Revenue Service has notified me that I am no longer subject to backup withholding, and 3. I am a U.S.
person (including a U.S. resident alien).
CERTIFICATION INSTRUCTIONS You must cross out item 2 above if you have been notified by the Internal Revenue Service that you are currently
subject to backup withholding because of underreporting interest or dividends on your tax return.
THE INTERNAL REVENUE SERVICE DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE
CERTIFICATION REQUIRED TO AVOID BACKUP WITHOLDING.
Primary Applicant Signature Required Date Authorized Signer Signature Required Date


MAIL COMPLETED APPLICATION TO: American Health Value, P.O. Box 8063, Boise, ID 83707

THE BANCORP BANK
Trustee under the agreement, hereby acknowledges receipt of the above application and successor designation.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ (By Authorized Officer)

Copyright American Health Value, LLC 2012 All Rights Reserved File: Form-Application-Bancorp Revised 09-29-13